ORAL HEALTH POLICY: WHAT DOES IT DO FOR RURAL AND REMOTE COMMUNITIES?

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ORAL HEALTH POLICY WHAT DOES IT DO FOR RURAL AND
REMOTE COMMUNITIES?
A/Prof Erica Bell Dr Len Crocombe Centre for
Research Excellence in Primary Oral Health Care
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ORAL HEALTH POLICY WHAT DOES IT DO FOR RURAL AND
REMOTE COMMUNITIES?
A/Prof Erica Bell Dr Len Crocombe Centre for
Research Excellence in Primary Oral Health Care
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Why oral health matters

• Expenditure on dentistry in 2009-10
• In Australia was 7.7b (AIHW, 2012).
• Those missing out on primary oral
• health care
• frail and older people (Chalmers 2002)
• rural residents (Crocombe et al. 2010)
• Indigenous Australians (Slack-Smith 2011)
• Australians with physical and intellectual
  disabilities (Pradhan et al. 2009)
• People of low socio-economic status (Sanders et
  al. 2006)

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Research evidence of what works and what does not
work in oral health

• Poor hygiene (Davies et al. 2003 Hujoel et al.
  2006)
• Poor diet (Rugg-Gunn, 1993)
• Lack of access to primary health care
  (National Oral Health Plan 2004-2013)
• Social determinants (Sanders et al. 2006)
• Smoking (Do et al. 2008)
• Low fluoride exposure (ARCPOH, 2006)

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Aims of the oral health policy study

•  
• Aim The ultimate aim of the study was to
  contribute to better understandings about what
  national government oral health policy has been
  developed and is needed for rural and
  disadvantaged communities
• Research questions 1)What kinds of content
  define national government oral health policy in
  OECD countries, particularly for rural and
  disadvantaged groups? and
• 2) What assumptions underpin the way national
  oral health policy documents describe the policy
  problems and solutions for rural oral health?

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The sample
Policy document and country Year
Together for health a national oral health plan for Wales draft consultation document 2012
Oral health program strategic plan 2011-2014 USA 2011
Oral health strategy for Northern Ireland   2007
Good oral health for all, for life The strategic vision for oral health in New Zealand 2006
A Canadian oral health strategy 2005
Choosing better oral health An oral health plan for England 2005
An action plan for improving oral health and modernising NHS dental services in Scotland 2005
Healthy mouths, healthy lives Australia's national oral health plan 2004-2013 2004
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Analytic procedure

• Stage 1. Policy document content scoping and
  quantification.
• Stage 2. Discourse analysis of key assumptions in
  policy problems and solutions for rural oral
  health.

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Results
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Results contd

• The rural concept is relatively infrequent (2)
  but often occurs with the more common workforce
  concepts
• The language of oral health policy documents is
  dominated by workforce and practitioner
  development concepts
• The 7 concepts for the rural and other
  disadvantaged groups are not the least frequent
  concepts in the study
• The rural concept is most present in the
  Australian and Scotland documents (7 and 4
  likelihood) 1 likelihood in the Canadian policy
  and is not found at all in the USA policy
  document.
• For the concept rural the three most frequent
  paired concepts are students (43),
  recruitment (36), Aboriginal and Torres
  Strait Islander (30-29). All other paired
  co-occurrences for the rural concept range from
  12 to 1. Generally speaking, the workforce
  development concepts tend to be more frequently
  paired with the rural concept than the wider
  social determinants of health concepts.

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Critical discourse analysis key enabling
assumptions of policy stories about rural oral
health

• In relation to causality, policy documents have
  three policy stories
• 1.1 The socio economic causality policy story.
• asserts a wide range of socio-economic factors
  contribute to unequal oral health outcomes in
  rural and remote Aboriginal communities, not
  clear which ones or how (AUS)
• asserts that the overall poorer health of rural
  and Aboriginal communities is linked to poorer
  oral health, not clear why or how (AUS)
• asserts lack of access to dental care by
  vulnerable groups, particularly rural communities
  and rural children, is driving inappropriate use
  of medical services (AUS)

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e.g

• Rates of edentulism (total lack of natural
  teeth) reflect the distribution of poor general
  health in the population. While about 10 percent
  of the Australian population is edentulous, this
  rises to 16 percent for the Indigenous
  population, and to nearly 25 percent for Health
  Card holders (AUS)

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1.2 The service model causality policy story

• Asserts private structure of oral health services
  a major barrier to preventative care and early
  treatment (AUS)
• Asserts declining oral health in some vulnerable
  groups linked to decline of public infrastructure
  (NZ, AUS)
• Complexity of mixed public and private service
  structures part of the problem of access for
  disadvantaged groups (SCOTLAND)

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1.3 The workforce causality policy story

• Asserts rural and remote workforce supply
  challenge is about culturally conditioned choices
  made by practitioners (CANADA)
• Asserts even when practitioners/services present
  there is unequal service utilisation and this is
  about the cultural appropriateness of
  practitioners and services (CANADA, AUS)

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In relation to solutions, policy documents have
three policy stories

• 2.1 The prevention policy solution story
• Asserts culturally appropriate health promotion
  and prevention is important, especially for
  children (CANADA, AUS)
• Fluoridation seen as a critical strategy for
  rural oral health (AUS)
• Asserts better access to preventatively focussed
  dental care important (AUS)

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2.2 The service model policy solution story

• Asserts community oral health services can
  achieve a service hub approach to childrens
  oral health esp. (NZ)
• Integrated hubs with regionally-agreed referral
  and care pathways are necessary (WALES)
• School-based oral health services can help in
  rural communities (CANADA)
• Aboriginal-controlled oral health services have
  demonstrated effectiveness (AUS)

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2.3 The workforce policy solution story

• Integration of workforce development approach and
  expanded scope of practice important (i.e.
  encompass a wide range of oral health
  professionals and non oral health professionals
  for alternative service delivery) (CANADA,
  SCOTLAND, AUS)
• Incentives can be wide-ranging (financial
  emphasised but not sure what ones really work)
  (CANADA, SCOTLAND)
• Range of strategies needed for increasing supply
  through training, recruitment and retention,
  including for public services (unclear what
  works) (SCOTLAND, AUS)
• Wide-ranging strategies for optimal distribution
  needed but unclear which ones really work (AUS)

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Preliminary conclusions

• Australia and some other nations have a strong
  in-principle policy commitment to rural and
  Aboriginal and other disadvantaged groups
• Butthe absence of policy documents, their dated
  nature, as much as their limitations in
  explaining poor oral health causes and providing
  solutions supports the view that oral health
  policy has been formed on an ad hoc basis
• The next step is to systematically examine the
  research evidence for key policy assertions

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Key references

• Bell E. Research for Health Policy. Oxford
  Oxford University Press, 2010.
• Nutley S, Davies H, Smith P. What Works? Evidence
  Based Policy and Practice in Public Services
  Bristol The Policy Press, 2000.
• Nutley S, Walter I, Davies H. Using Evidence How
  Research Can Inform Public Services Bristol The
  Policy Press, 2007.
• Majone G. Evidence, Argument Persuasion in the
  Policy Process USA Yale University Press, 1989.
• Stone D. Policy Paradox The Art of Political
  Decision-Making. 2nd ed. ed New York W.W.
  Norton, 2002.